Squamous Cell Carcinoma of the Sigmoid Colon: A Path Less Traveled - Cureus

Open Access Case Report

DOI: 10.7759/cureus.22297

Review began 01/31/2022 Review ended 02/07/2022 Published 02/16/2022

? Copyright 2022 Ramachandra et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CCBY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Squamous Cell Carcinoma of the Sigmoid Colon: A Path Less Traveled

Deepti Ramachandra 1 , Gourav Kaushal 2 , Anvin Mathew 1 , Puneet Dhar 1 , Nirjhar Raj Rakesh 1

1. Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, IND 2. Surgical Gastroenterology, All India Institute of Medical Sciences, Bathinda, IND

Corresponding author: Gourav Kaushal, drgauravkaushal@

Abstract

Squamous cell carcinoma (SCC) involving the gastrointestinal tract is exceptionally rare, except in the esophagus and the anal canal. In the hindgut, a common site of involvement is the colo-rectum, commonly seen in the fifth decade of life. The presentation is usually in the advanced stages and carries a poor prognosis. Due to the rarity of the disease, before labeling it as a primary lesion, the possibility of metastasis from a distant primary should be entertained. Consensus guidelines regarding the management of such a rare condition are lacking. Here, we present the case of an elderly gentleman with a history of surgery for urinary bladder cancer 20 years back (the nature of which is not known). The patient presented with left lower abdominal pain and altered bowel habits. His pain had persisted for approximately two months along with a recent onset of overflow incontinence but no other associated constitutional symptoms. Examination revealed pallor and a vague abdominal mass in the left iliac fossa. On further evaluation with a colonoscopy, a growth was seen in the sigmoid colon. Computed tomography of the abdomen revealed a locally invasive growth arising from the sigmoid colon along with a space-occupying lesion in the left lobe of the liver enhancing on the portal phase. Biopsy from the sigmoid and the liver lesion was reported as SCC which was confirmed by immunohistochemistry. Given the metastatic nature of the lesion, treatment options were discussed in a multidisciplinary team setting, and the decision was made to proceed with diversion colostomy and palliative chemotherapy. SCC of the colon is a rare disease and is usually diagnosed at an advanced stage. Even in operable cases, the prognosis is dismal, and various treatment modalities have been attempted. Due to the rarity of the disease and paucity of data regarding definitive management, treatment varies from one patient to another.

Categories: Pathology, General Surgery, Oncology Keywords: bladder cancer, metachronous cancer, second primary, squamous variant, colon cancer

Introduction

Primary squamous cell carcinoma (SCC) of the gastrointestinal tract (GIT) is rare, except in the esophagus and anal canal. The most common location of SCC in the hindgut is the colo-rectum [1]. It accounts for approximately 0.1-0.25% per 1,000 diagnosed colorectal carcinomas [2]. In the early 20th century, Schmidtmann reported SCC of the caecum, and Raiford published SCC of the rectum [3]. Most cases have been reported in the rectum and appear to affect both genders, but colonic lesions appear to have a male preponderance and are thought to present by the fifth decade of life [4,5]. Presentation is usually in advanced stages and carries a dismal prognosis [5]. Metastasis from a distant primary should be entertained before labeling it as a primary lesion. Metastasis is usually to the small bowel, especially from the lungs. As the disease is rare, definite consensus regarding the management is lacking. Here, we present the case of a patient who developed a second primary (colonic SCC) after undergoing radical cystectomy and an ileal conduit for urinary bladder carcinoma.

Case Presentation

Our patient was an elderly gentleman with no medical history but a surgical history of radical cystectomy and an ileal conduit formation two decades ago for urinary bladder malignancy. The nature of the urinary bladder lesion could not be ascertained due to a lack of records. The patient presented with pain in the left lower abdomen and altered bowel habits for two months along with symptoms of overflow incontinence for a week. He had no anorexia, weight loss, or any rectal symptoms. He provided a history of tobacco use in the form of 20 beedis per day but had quit about 25 years ago. In addition, he provided a history of occasional alcohol consumption before the diagnosis of urinary bladder cancer and had quit ever since. His family history was non-contributory. On examination, he was a thinly built man with a body mass index of 21.6 kg/m2 and a good performance score (World Health Organization score 1). He had mild pallor, and the rest of the general examination was non-contributory. Abdominal examination revealed a well-healed midline laparotomy scar with a healthy urostomy in the right lumbar region. A vague mass was palpable in the left iliac fossa of the abdomen. On evaluation with basic blood parameters, he was found to have anemia and hypoalbuminemia (Table 1). On evaluation with colonoscopy, an ulceroproliferative lesion was seen in the sigmoid colon approximately 35 cm from the anal verge. Further evaluation with computed tomography (CT) showed that the lesion was invading the serosa, the obturator canal, and the rectum, along with a space-

How to cite this article Ramachandra D, Kaushal G, Mathew A, et al. (February 16, 2022) Squamous Cell Carcinoma of the Sigmoid Colon: A Path Less Traveled. Cureus 14(2): e22297. DOI 10.7759/cureus.22297

occupying lesion (SOL) in segment IV of the liver, which was enhancing on the portal phase (Figures 1, 2). Contrast CT of the thorax ruled out metastasis to the lung. The lesion in the sigmoid was biopsied during colonoscopy, and a percutaneous core biopsy of the liver SOL was performed. Histopathological examination from the lesions revealed features of SCC (Figure 3) which was confirmed on immunohistochemistry (P40+, negative for caudal-type homeobox 2, and cytokeratin 20) (Figures 4-6). After a multidisciplinary team discussion, in view of the advanced nature of the lesion with obstructive features and failed colonoscopy stenting, the patient underwent diversion sigmoid colostomy. Postoperative recovery was uneventful, and he was discharged home on postoperative day five. Chemotherapy with paclitaxel and carboplatin was resumed for palliation. At the six-month follow-up, the patient was well, had gained weight, and had partial tumor response.

Investigation

Results

Normal range

Hemoglobin

10.5 g/dL

13?17 g/dL

Blood urea

30 mg/dL

17?50 mg/dL

Creatinine

0.89 mg/dL

0.7?1.2 mg/dL

Total bilirubin

0.7 mg/dL

0.3?1.2 mg/dL

Direct bilirubin

0.2 mg/dL

0?0.2 mg/dL

Aspartate aminotransferase

29 U/L

0?50 U/L

Alkaline aminotransferase

43 U/L

0?50 U/L

Alkaline phosphatase 110 U/L

30?120 U/L

Albumin

3.1 g/dL

3.5?5.2 g/dL

Prostate-specific antigen

0.04 ng/mL

0?4 ng/mL

Carcinoembryonic antigen

1.7 ng/mL

0?2.5 ng/dL

Colonoscopy

There was an ulceroproliferative growth in the sigmoid colon approximately 35 cm from the anal verge, and the scope was non-negotiable beyond the lesion

-

Histopathology

Infiltration of the tumor with polygonal cells having moderate eosinophilic to clear cytoplasm and hyperchromatic nuclei and nucleoli, suggestive of squamous cell carcinoma

-

Immunohistochemistry on tissue block

Positive for P40, and negative for cytokeratin 20 and caudal-type homeobox 2

-

Large ulcerated mass lesion approximately 5.3 ? 4.4 ? 7.9 cm in size noted in the proximal sigmoid

Triphasic contrast CT scan of the abdomen

colon, causing a stricture measuring approximately 10 ? 11 cm and locally invading the serosa and involving the adjacent obturator space and obstructed bowel colon with feral loading. In addition, a hypoenhancing tumor approximately 2.4 ? 2.5 cm in size noted in segment IVA of the liver showing

-

peripheral enhancement in the portal phase

Contrast CT chest

Calcified nodules in the upper zone and a subcentimetric left subpleural lesion. No lesions were suggestive of malignancy

-

TABLE 1: Basic blood investigations, imaging, colonoscopy, and histopathology findings.

2022 Ramachandra et al. Cureus 14(2): e22297. DOI 10.7759/cureus.22297

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FIGURE 1: Coronal section of contrast CT scan of the abdomen.

The arrow denotes circumferential thickening of the segment of the sigmoid colon causing a stricture and upstream dilatation of the loop of the colon. The lesion extends beyond the serosa and invades the adjacent rectum.

2022 Ramachandra et al. Cureus 14(2): e22297. DOI 10.7759/cureus.22297

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FIGURE 2: Axial section of contrast CT of the abdomen.

The arrow shows a mass lesion in the sigmoid colon and involves the left obturator space.

FIGURE 3: Axial section of triphasic CT of the abdomen.

The arrow depicts a hypoenhancing, space-occupying lesion in the segment IV of the liver with peripheral enhancement on the portal phase.

2022 Ramachandra et al. Cureus 14(2): e22297. DOI 10.7759/cureus.22297

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FIGURE 4: Histopathology slide of the colonoscopic biopsy specimen.

The arrow shows sheets of polygonal cells with eosinophilic cytoplasm.

FIGURE 5: Immunohistochemistry of the colonoscopic biopsy specimen.

The arrow shows positively stained (brown) P40-expressing cells.

2022 Ramachandra et al. Cureus 14(2): e22297. DOI 10.7759/cureus.22297

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